Fig 1.
District-level expansion across provinces in Zambia (2006–2014) and projected (in 2016) of the Cervical Cancer Prevention Program in Zambia (CCPPZ).
Fig 2.
Clinic-level expansion in the Lusaka province (2006–2014) of the Cervical Cancer Prevention Program in Zambia (CCPPZ).
Fig 3.
Performing VIA-based screening augmented by digital cervicography in the clinics of the Cervical Cancer Prevention Program in Zambia (CCPPZ).
Notes: Nurses in CCPPZ clinics initially perform screening using VIA, after which they use a commercial brand (off-the-shelf) hand-held digital camera (Upper Panel) to take photographs of the cervix (cervigrams). Cervigrams are then displayed on a bedside television or camera monitor in real-time (Middle Panel), permitting magnification and detailed examination of lesion morphology, including size, margin sharpness, proximity to the transformation zone, degree of extension into the endocervical canal, abnormal vasculature (mosaicism, punctations, atypical blood vessels) and gross characteristics suspicious for ICC. Cervigrams are routinely shown to and discussed with patients during the screening procedure after which they are uploaded by nurses to a clinic computer where they can be (i) electronically transmitted using cellphone network lines to off-site experts (after deidentifcation) for rapid distance consultation (telecervicography), when necessary, (ii) batched and later routinely peer reviewed to form the basis of a rigorous ongoing continuing education and quality assurance program, and (iii) stored with the patient’s electronic medical record. Relevant cervigrams are transmitted by screening nurses to the referral clinic by email, after deidentification, where they are accessible by consultants at the time of patient visits. (Lower Panel).
Fig 4.
Images of VIA negative, VIA positive-cryotherapy eligible and VIA positive-cryotherapy ineligible lesions from women undergoing screening in the Cervical Cancer Prevention Program in Zambia (CCPPZ).
Notes: Using the following criteria, CCPPZ nurses classify VIA tests results as VIA negative, VIA positive eligible for local ablation with cryotherapy, or VIA positive ineligible for cryotherapy requiring physician evaluation.
- VIA negative: Absence of an acetowhite lesion with at least one distinct border (Top Panel, Left)
- VIA positive, eligible for cryotherapy: Acetowhite lesion with at least one distinct border, located within or adjacent to the transformation zone, that: occupies <75% or <3 quadrants of the surface of the ectocervix, is completely visualized, can be completely covered by the largest available cryoprobe tip, has no evidence of abnormal vasculature (punctations, mosaicism, atypical blood vessels) and is not suspicious for ICC (Top panel, right)
- VIA positive, ineligible for cryotherapy: Acetowhite lesion with at least one distinct border, located within or adjacent to the transformation zone, that has any of the following characteristics:
- Occupies ≥3 quadrants or ≥75% of the surface of the ectocervix (Middle panel, left)
- Has evidence of abnormal vasculature (punctations, mosaicism, atypical blood vessels) (Middle panel, center)
- Cannot be completely covered by the largest available cryoprobe tip (Middle panel, right)
- Is suspicious for invasive cervical cancer (Bottom panel, left)
- Extends into the endocervical canal beyond complete visualization (Bottom panel, right)
Table 1.
Socio-demographic and sexual and reproductive characteristics of participants in the Cervical Cancer Prevention Program in Zambia (CCPPZ) during 2006–2013.
Fig 5.
Program process and outcome indicators of the Cervical Cancer Prevention Program in Zambia (CCPPZ).
Panel A (Top, left): Trends in HIV status of screened women over the calendar years 2006–2013. Panel B (Bottom, left): Rates of screening positivity, cryotherapy eligibility and cryotherapy-ineligiblity by age categories and overall. Panel C (Bottom, right): Trends in rates of screening positivity and cryotherapy rates over calendar years 2006–2013. Panel D (Top, right): Trends in rates of ‘same day-services’ and rates of ‘appropriate referral’ over calender years 2006–2013.
Table 2.
Programmatic process measures (screening and treatment uptake by HIV status) in the Cervical Cancer Prevention Program in Zambia (CCPPZ).
Table 3.
Programmatic outcome measures (cervical intraepithelial neoplasia and invasive cancers detected among screen-positives by HIV status) in the Cervical Cancer Prevention Program in Zambia (CCPPZ).
Table 4.
Critical Problems and Practical Local Solutions in the Cervical Cancer Prevention Program in Zambia (CCPPZ) (list not exhaustive, for illustrative purposes only).